Please help us to trace your medical records by providing the following information:

Address in UK when last registered with a GP

Name and address of previous GP practice in UK

Postcode

Postcode

If you are from abroad

Date you first came to live in the UK

If returning from abroad, date of departure from UK

Your most recent country of residence

If you have served in the British Armed Forces

Enlistment date

Service Number

Are you a reservist?

YesNo

If yes, please provide your address before enlisting

Postcode

Leaving date

Is this your first registration with a GP since leaving the armed forces?

YesNo

Voluntary consent to organ donation

I would like to join the NHS Organ Donor Register as someone whose organs may be used for transplantation after my death.
Please tick the boxes that apply. Your consent to organ donation will be shared with NHS Blood and Transplant together with the information you
have provided in Section 1 including your name, gender, date of birth address and CHI number. For more information on being an organ donor or
privacy, please ask for the leaflet on joining the NHS Organ Donor Register or visit http://www.organdonation.nhs.uk.

Any OrganKidneysLiverLungsHeartCorneasPancreas

Patient's / Patient's representative signature: (you will need to sign this at the practice)

Date:

How we use your information

The information you have provided will be used by the GP Practice to carry out its various functions and services including
scheduling appointments, ordering tests, hospital referrals and sending correspondence.

Your information, including your name, gender, date of birth and address, will be passed to NHS National Services Scotland where it
will be held on the Community Health Index (CHI). This information is used to register you with the GP Practice, transfer your
medical records between GP practices in the UK, make payments to GP Practices for medical services provided, and to process and
issue medical cards, medical exemption certificates and entitlement cards.

NHS National Services Scotland shares information about you within NHSScotland to assist in the provision and improvement of
NHS services and the health of the public. When we do this, we make sure that the information which identifies you as a person and
your health information are separated or anonymised. Health condition and treatment information which could identify you will not be
used for research purposes by the NHS unless you have consented to this.

For more information on how NHS National Services Scotland uses your personal information visit http://www.nhsnss.org. If you have any
queries or concerns about how your personal information is used by the NHS please ask for the leaflet ‘Confidentiality – it’s your
right’, visit the Health Rights Information Scotland website at http://www.hris.org.uk or ask your GP surgery.
NHS National Services Scotland is the common name of the Common Services Agency for the Scottish Health Service.

Patient Declaration

I declare that the information I have given on this form is correct and complete. I understand that, if it is not, appropriate action may be taken.
To enable NHS National Services Scotland to confirm my eligibility to lawfully register with a GP and for the purposes of prevention, detection, and
investigation of crime, relevant information from this form will be disclosed to the NHS Business Services Authority, NHS National Services Scotland,
the Home Office, Identity and Passport Service, HM Revenue and Customs, the General Register Office and Local Authorities.

Patient's / Patient's representative signature: (you will need to sign this at the practice)

Date:

Representative's Name (if applicable)

Relationship to patient (if applicable)

Please note that by using this form you will be sending information about yourself
across the Internet. Whilst every effort is made to keep this information secure,
you should be aware that we cannot offer any guarantees of absolute privacy. If
this matter concerns you then you should use another method of registration.

Personal information retained on this system is stored in a secure data centre located
in the UK and is treated as confidential.

About This Form

Fields marked with a red asterisk arecompulsory.

You should only send this form if you are sure that you are eligible to join this
practice.

Sending this form will NOT automatically register you with the surgery.

Your details will be kept at the surgery and must be signed by you during your first
appointment.

Sending this form does NOT guarantee or even imply that you will be accepted onto
the practice register